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an excerpt

The office had that smell that all medical facilities have. Some mixture of betadine, alcohol and the air freshener that was designed to cover up the first two combined to create that unique environment.

Nurses and assistants shuffled through the corridors leading patients to waiting rooms. Emphasis on the waiting. Billing clerks shuffled paper at their own pace while the lynchpins of the whole operation, the doctors themselves, shuffled files and scurried to see the next patient for whom they must diagnose and advise in just 12.5 minutes or risk showing up on some consultant’s exception report.

This was the world of Managed Care. Managed chaos, managed to do nothing, managed to screw things up, these are the names given by those who try to manage their patients’ issues as well as their malpractice risk every day.

In the late ‘70s, when Elizabeth went through med school, these terms hadn’t become part of the medical vernacular. Neither had cat scans, MRIs, HMOs or “distance medicine”. Diabetes was still an uncommon affliction. So was obesity.

Medicine was a noble profession then and one she’d come to after spending a lonely 2 years at Georgia Tech. There were few girls there then and most weren’t welcome. Maybe that was a blessing in disguise. In her Junior year she transferred to Emory where she briefly considered amajoring in archeology. Her roommate was a biology major. Always bookish, she started pursuing Amy’s textbooks and development an interest in anatomy. That led her to medicine. As a pre-med, she learned about life.. not just in a petrie dish, but from professors, admissions committees and the competitive antics of her classmates.

She spent a year after residency in Alaska, in a program that would wipe away her student loans. She returned to Atlanta after an offer from a large internal medicine practice was too attractive to turn down.

Today though, she spent most of her time seeing the same issues, repeating the same script: “You’re showing the signs of insulin resistance, which is a pre diabetic condition. Some things you can do to improve your chances of this not turning into full blown diabetes is lose some weight” (fill in the double, often triple-digit, number of pounds here) It will help to eat a more balanced diet, and exercise”.

Then the overweight patient nodded politely with a vacant look that tacitly confirmed that no lifestyle changes would be made even though they were essentially receiving a slow death sentence. “ Cant you just prescribe something that will fix this”, was the common response. Her patients, as you might expect, spent too much time in front of the TV and thus had become well trained by the pharmaceutical industry to expect that there is a pill for every ailment. “Just ask your doctor about…..” No personal responsibility needed, no self control required.

On the other end of the spectrum were what Elizabeth referred to as the “health is my godgiven right” patient. Often baby boomers who’d not come to terms with their mortality, they exercised, ate well, did yoga, meditated. These patients often had watched a sibling or parent who’d lose their battle to cancer, heart attack or alcoholism. Some were health zealots. Some were just quietly careful of their “lifestyle choices”. Almost all were affluent with good insurance. They felt that they were doing the all the right things and should therefore live (and run, bike and golf) until they reached 100. These folks felt shocked and betrayed, when despite their best efforts, they were tapped on the shoulder by the health fairy.

It’s easy for a doctor to quietly believe that some patients bring on their own problems. It’s more frustrating and saddening when a diagnosis of one of the many more random diseases hits an otherwise healthy patient. Elizabeth had seen evidence of multiple sclerosis, early stage Parkinson’s, and ALS and leukemia . The question was always “why me, what did I do wrong” and she never had a good answer. It was the stress of these social issues rather than the administrative or economic ones that began to wear on her as a physician.

First, it started as a mild dread of Mondays. It became harder to get out of bed. She’d spend extra time listening to NPR and conjuring up excuses for calling in sick. She laughed at herself for doing what others do… not those who’ve committed their life and career to taking care of those who needed it.

The wear began to take on other forms—a mild cynicism towards patients. With out even seeing them, only the scribbling of the nurses notes, she could profile the personalities those who were in chronic bad health.

Whereas she had always saved her vacations, she began taking random days and spending them alone in her garden. The garden quickly expanded given the extra time that Elizabeth offered it.

It late in the spring when the “final patient” came in. This wasn’t really the final patient of course. Elizabeth knocked softly on the exam room door.

“Come in” was the response, in a gravely voice. She opened the door knowing that there was a heavy smoker on the other side.

“Hello, Mr Perry, I’m Dr Gibson”.

“Hello.”

So, I see you’re here today because you’re having trouble sleeping at night?

“Well yes, I keep waking up coughing”

Do you smoke, Mr Perry? She asked solemnly, already knowing the answer.

“Well sometimes…”

“How much do you smoke? How many cigarettes per day?”

“I haven’t really counted. I had a doctor ask me that several years ago, but I started to feel better so I quit trying to count.

Here we go, she thought. This is someone who’s either in denial or knows how to play the game. “Well, how much do you think you spend on cigarettes a week? Do you know?”

“I’d say maybe 50 or 100 dollars.”

“That’s a pretty big range. And a lot of cigarettes. Has anyone talked with you about trying to quit.” She tried to sound as non-confrontational as possible.

“Yeah, the nurse at the factory where I work, she’s always reminding me how bad it is. Thing is, I just can’t quit. I get these cravings and these moods and I just can’t help myself. I was hoping you could give me something to help me sleep”.

After examining the patient and holding in her frustration as she’s been well trained to do, she offered. “Mr Perry, you’ll never get a good night’s sleep as long as you have the persistent irritation in your throat. And as long as you smoke, you’ll have that irritation. Now what I ‘d like to do is this: I’d like to schedule for a more extensive exam on your throat. In a long term smoker there is big risk of changes to the tissue in your throat and I’d like to rule that out. And….”

“What do you mean by changes in the tissue?” There was concern in his voice.

Elizabeth was heartened by this response. “Maybe I’ve gotten through to him.”

She explained that smoking caused changes to cells which often led to precancerous and then cancerous spots or lesions.

His response: “Well.”

The man began looking around the room as she continued: “I’d also like write a prescription for you to go to a smoking cessation program. That way, your insurance should cover it. I’ll also prescribe you a mild cough suppressant. That should help your cough so you can sleep.

As she handed him the 2 prescriptions, he stood and opened the door. He looked at her with contempt in his eyes and said “all I wanted was some of those new sleeping pills” as he walked out.

Elizabeth sat at the exam desk with her head in her hands. Her assistant knocked quietly.

“Come on in”.

“Your patient tossed his paperwork in the trash on his way out. What gives?”

Elizabeth took a deep breath. “You know. Doesn’t want to see the writing on the wall.” She paused and looked earnestly at the nurse. “What are we gonna do about these people?”

“Nothing we can do, they won’t help themselves. Don’t know why they even come in here. My momma’s the same way. So’s my sister. Can’t talk to her either. Can’t tell her nothing.”

“That must be hard”.

“Ugh! You know that!” she shrugged. “Your next patient is in room 4”. The nurse tossed her the file like a frisbee, grinned, rolled her eyes and walked out.